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By James Vertino, Chief Executive Officer

When you make strategic healthcare decisions based on data, good things happen for clients and members.

That’s why many companies, including EBMS, chose The Milliman Advanced Risk Adjusters (MARA) tool. It is the perfect complement to my company’s data-driven approach to benefit plan evaluation and management.

Risk-adjustment processes like MARA have replaced traditional medical underwriting in recent years – and for good reason. MARA uses each member’s medical and prescription drug claim history to predict the individual’s relative healthcare cost risk, as compared to an average population risk.

Using a risk-assessment tool like MARA, payers can identify high-risk patient populations and then take action to mitigate the associated costs through various care-management programs

MARA provides an exceptional level of detail, which our clients can use to make more strategic decisions. We receive category risk scores for different health services, such as inpatient, outpatient, emergency room, and prescription.

Using this prospective model of risk scoring allows EBMS to focus on predicting which individuals may incur high costs in the near future. It is those individuals who may benefit from care interventions right now.

Risk stratification for care-management purposes can be quite complex. For example, we know that only a small percentage of plan members incur high spending each year. In fact, the top 5 percent of spenders can account for up to half of all healthcare dollars.

However, the Health Care Cost Institute reported in 2018 that there is high turnover among these top spenders . It found that, during each year studied, more than three of five top spenders were not top spenders during the previous year.

That’s where a tool like MARA is invaluable. When clients see a decrease in their average total risk score, it indicates a positive trend for expected health costs and outcomes. It is this kind of data analytics that helps clients make more strategic decisions.

Not every company is using tools like MARA – yet – but the momentum is building. You might check with your TPA to see what tools they have in their toolkit that might benefit your organization.